complaint·January 23, 2024

Record review of the facility daily notes revealed on 01/07/2019, R1 experienced an unwitnessed fall and no injuries were noted. On 02/12/2019, R1 fell and was subsequently taken by ambulance to the hospital. The hospital's emergency department (ED) records dated 02/12/2019 revealed R1 was brought in by ambulance after a fall at home due to R1 picking up an orange peel, lost balance, and fell. ED records revealed R1 sustained a contusion to the right orbit. On 06/06/2019, R1 fell and hit their head, and was taken to the hospital. Hospital ED records dated 06/06/2019 revealed R1 slipped on the bed and hit their head on the floor. ED records revealed R1 was diagnosed with right lateral frontal scalp hematoma swelling. On 06/10/2019, R1 fell and facility notes read “R1 falling by bed and nightstand – was not hurt”. On 06/11/2019, facility notes read “last night R1 slipped off bed, R1 don’t want anybody to know”. On 07/26/2020, R1 fell and was transported by ambulance to Riverside University Health System sustaining a cervical fracture. Interviews with facility staff revealed R1 would often refuse any assistance, despite having poor balance and prone to falls, and would attempt to do tasks by themselves without requesting assistance. As R1's health declined and R1 had multiple falls, the facility worked with R1's family to formulate a verbal care plan to ensure facility staff were providing as much care and supervision as possible for R1. The formulated care plan included: staff checking on R1 every 2 hours, switching R1's bed to a hospital bed with bed rails per Physician Orders, and encouraging staff to walk beside R1 when they ambulated. Interview with R1’s responsible party (RP) on 09/17/2020 revealed they were notified of R1’s falls and RP worked with the facility to discuss plans to address safety concerns after each fall. RP stated bedrails were placed on R1’s bed and was informed staff will check on R1 more often. Interview with Staff One (S1) revealed staff always had to watch over R1 but after R1 returned from the hospital from their last fall in July 2020 they were informed to check on R1 every two hours and to watch R1 closely. S1 stated R1 received the hospital bed with the bed rails around August 2020 or September 2020. Interviews with staff revealed they were aware of the verbal care plan and implemented staff checks on R1 every two hours, offered more assistance to R1, and monitored R1 as they moved around at the facility. Staff were aware that R1 needed a hospital bed with bedrails. Interview with relevant residents revealed staff provide care and supervision and assist when requested. It was revealed that R1 will try to get out of their wheelchair on their own and staff will assist even when R1 does not request assistance. Through the Department’s investigation it is unclear if R1's fall was as a result of neglect, or an accident aided by R1's decline in health and unwillingness to request or accept facility staff assistance. Therefore, based on the Department’s investigation the allegation "Staff neglected resident over time resulting in multiple falls with injuries" has been deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are not properly trained” LPA conducted interviews with staff and residents and conducted record review in relation to the allegation. Information received from interviews and record review reveal facility holds quarterly training every year with documentation of training from 2020. In-House training sign-in sheets from 2020 was provided to LPA but not the certificates of completion for staff in attendance due to record retention time frame. It was also confirmed Staff who completed the training in 2020 no longer work at the facility. In-house training sign-in sheet and training certificates from 2023 were provided to LPA for record review. LPA conducted interviews with Resident Two (R2) who stated Staff Two (S2) had “saved their life” due to observing changes in R2’s physical behavior were different and immediately contacted emergency services. Therefore, based on LPA’s information obtained from interviews and record review the allegation has been deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are not properly feeding resident while in care” LPA conducted interviews with staff and residents and conducted record review in relation to the allegation. LPA conducted interviews with R1 inquiring about the quality and quantity of food R1 receives. R1 stated the facility always provide meals and snacks to R1 and R1 has never had any issues with not being properly fed. LPA’s interview with Administrator Plascencia revealed that the facility hired a cook to come every day to prepare the residents’ breakfast, lunch, and dinner to ensure residents are properly fed. LPA’s record review of the menu corroborated with the lunch the residents were served during LPA’s visit. During the facility tour, LPA observed the facility had the required amount of perishable and non-perishable food available per Title 22 regulations. Therefore, based on LPA’s information obtained from interviews, record review, and observation, the allegation has been deemed UNSUBSTANTIATED at this time. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report was provided to Administrator Plascencia along with LIC811-Confidential Names.